Community Care Licensing

Document is an Amendment of Original Document on 06/02/2023 09:57 AM

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Komal Charitra TELEPHONE: (650) 266-8800 LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023

FACILITY NAME: PSALM RESIDENTIAL CARE HOME	FACILITY NUMBER: 385600432
	VISIT DATE: 05/16/2023

Document is an Amendment of Original Document on 06/02/2023 10:01 AM

FACILITY NAME: PSALM RESIDENTIAL CARE HOME	FACILITY NUMBER: 385600432
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/17/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation:(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator to develop a plan in writing to repair the facility's floors. Licensee to schedule a pest control inspection and submit a plan to maintain facility in good repair
	8 9 10 11 12 13 14	Based on observations, several areas of the facility had unbalanced, ripped, cracked floors and in some areas, there were burn holes observed. In addition, the Department observed a mouse run under a resident’s bedroom dresser.	8 9 10 11 12 13 14
Type A 05/17/2023 Section Cited CCR87307(a)(2)(A)	1 2 3 4 5 6 7	87307 Personal Accommodations: (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortabl living accommodations and privacy for the residents…who may reside in the facility…: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (A) Bedrooms shall be large enough to allow for easy passage between and comfortable usage of beds and other required items of furniture specified below… Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	*AMENDED* Licensee/Administrator to develop a plan in writing describing how Licensee/Administrator and/or facility staff can ensure resident rooms are clear from clutter. Licensee/Administrator to develop a plan or document if residents choose to not allow staff to clean resident’s rooms.
	8 9 10 11 12 13 14	During the facility tour, resident rooms were observed to be cluttered with personal belongings; clothes, shoes, boxes, bins, furniture, etc.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Komal Charitra TELEPHONE: (650) 266-8800 LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023

Document Has Been Signed on 05/16/2023 12:36 PM - It Cannot Be Edited

FACILITY NAME: PSALM RESIDENTIAL CARE HOME	FACILITY NUMBER: 385600432
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/17/2023 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to conduct an in-service training regarding locking medications. Licensee to submit a written plan to ensure facility staff are following facility's protocols regarding locking medications so it's inaccesible to residents.
	8 9 10 11 12 13 14	Based on observations, the medication cabinet was observed to be unlocked and open when the Department was interviewing with the Licensee. In addition, during a facility sweep that was conducted by the Department, multiple pills were observed left out on the floor or on resident’s nightstands.	8 9 10 11 12 13 14
Type A 05/17/2023 Section Cited CCR87355(e)(2)	1 2 3 4 5 6 7	87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	Licensee filled out LIC9182 (fingerprint transfer) and provided a copy to LPAs during visit to associate individual.
	8 9 10 11 12 13 14	Based on record review, S1 was observed to have active fingerprint clearance, however, was not associated to the facility. According to the Licensee, S1 is a family member who resides at the facility	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Komal Charitra TELEPHONE: (650) 266-8800 LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023

Document Has Been Signed on 05/16/2023 12:36 PM - It Cannot Be Edited

FACILITY NAME: PSALM RESIDENTIAL CARE HOME	FACILITY NUMBER: 385600432
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/17/2023 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	87463 Reappraisal: (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to… Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to develop a plan in writing regarding reassessing residents after returning from hospital and/or after residents have a serious incident
	8 9 10 11 12 13 14	Based on record review and interview conducted, the Licensee failed to reassess residents after they returned from the hospital due to overdosing on drugs at the facility.	8 9 10 11 12 13 14
Type A 05/17/2023 Section Cited CCR87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to develop a plan in writing to address how the facility will monitor visitors at night when staff are sleeping.
	8 9 10 11 12 13 14	Based on observations, the front door of the facility, the kitchen door, the side door to the parking lot, and the back door were all unlocked and/or open. In addition, the Department witnessed a resident from another building entering the parking lot with a key. Furthermore S2 indicated that there were a couple incidents were he/she threatened to call the police on the homeless individuals and prostitutes that would come into the facility.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Komal Charitra TELEPHONE: (650) 266-8800 LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023

Document Has Been Signed on 05/16/2023 12:36 PM - It Cannot Be Edited

FACILITY NAME: PSALM RESIDENTIAL CARE HOME	FACILITY NUMBER: 385600432
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/17/2023 Section Cited CCR 87205(a-b)	1 2 3 4 5 6 7	87205 Accountability of Licensee Governing Body: (a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. (b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. Violation of this regulation is not met as evidence by	1 2 3 4 5 6 7	Licensee to develop a plan in writing on how Licensee can meet CCR 87205. In addition, Licensee to develop a plan on how to notify required parties if there are concerns at the facility
	8 9 10 11 12 13 14	The licensee failed to demonstrate accountability and take action when he found that residents are using drugs in the facility. In addition, the Licensee failed to be responsible to communicate with the Department, San Francisco Department of Public Health Placement Team, Long-Term Care Ombudsman and resident’s responsible parties, regarding the following drug issues at the facility.	8 9 10 11 12 13 14
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SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Komal Charitra TELEPHONE: (650) 266-8800 LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023